Two Major 21st Century Public Health Challenges

Inequalities in health pose the challenge supreme over all others to public health
professionals in developed countries. The “Black Report”, the product of the
committee set up by the UK Government in the late 1970s to investigate health
inequalities in UK, was published in 1980 (1). It opened the eyes of a
generation to the extent of the health gap between the health experienced by the
more prosperous in developed countries and that of the more deprived parts of
such populations. This is demonstrated by very marked differences in life
expectancy of those living in prosperous parts of our cities as compared with
that of those living in more deprived areas. In London it has been shown that
life expectancy falls steadily, tube station by tube station, as one travels
eastward on the District Line from the West End; similar findings have been
demonstrated in many other cities; Molony and Duncan (2) have described
analogous findings in Glasgow, where a traveller on the suburban train line
service between Jordanhill, in the West End, and Bridgeton in the East End,
would pass through a two year reduction in life expectancy between each
adjacent stations where the trains stop along the line.

Since the “Black Report” there have been many similar studies in various
European countries, including the UK (1, 3, 4). Actually, Syme and Berkman
(5) had published similar findings in the USA as early as the 1970s, but it seems
that these reports were considered so shocking at that time, and outside the
bounds of appropriate scientific enquiry, that they were almost hidden away,
and treated almost as “samizdat literature” (as described by Marmot (6)).
However, Marmot himself and his colleagues have thrown considerable light on
health inequalities through their reports on the social determinants of health (7,
8, 9), which include the main aetiological factors responsible for health
inequalities. Meanwhile, Pick and Wilkinson (10) have shown us that, in
countries where the gap between rich and poor is narrow (such as in Sweden or
Japan), the health status of everyone (including the rich) is superior to that of
everyone in countries where the gap between rich and poor is much wider (such
as in USA and UK). On the other side of the Atlantic, Deaton has written a
very readable account of many of the issues concerning health, wealth and
inequality (11), including a useful historical overview of the subject.
Marmot has provided (6) many potential entry points at which public health
workers might obtain entry into these problems, bringing public health skills
and approaches to bear on at least limited aspects of them. Molony and
Duncan have described the health inequalities situation in Scotland, and how
this is being addressed there. However, such activity in reality can provide
little more than tinkering around the edges of the matter; inequalities of health
and the social determinants responsible for these are the outcome of the
economic system prevalent in the developed world, and ultimately the solutions
can only really be economic ones. Such evidence as there is indicates that
health inequalities were much narrower in all western countries when
Keynesian economics reigned supreme, from 1945 to 1975, and then they began
to widen, and have continued to do so, as neoliberal economic policies replaced
Keynesian ones (12). There are some signs, both in north America and in
Europe, that neoliberal policies are being questioned ever more severely;
maybe we are entering an era when economics ministers may prove to be more
responsive than in recent history to the health needs of the more deprived parts
of the populations of developed countries.

The other major challenge to public health consists of nutrition, and the major
policy areas now inevitably associated with it. Our most major health problems
are caused either by over-nutrition and obesity or by malnutrition (13, 14).
Hogler and colleagues (13) remind us of the need to continue to address
malnutrition, including in developed countries, while Xiaohui Hou demonstrates
the importance of addressing, in particular, maternal and child under-nutrition in
developing countries (14). Birt (15, 16) has described the extent to which in
Europe there is almost a mismatch between the food grown and produced
(agricultural policy) and the types of food most needed by European
populations for their healthy nutrition, and Pushkarev (17) has described how
the EU, through reform of the Common Agricultural Policy, should build public
health nutrition into this. Meanwhile, over the last 30 years there has been an
increasing awareness of the environmental threats posed by modern farming
practices. These are numerous, but have become especially visible now we are
aware that farming contributes more global warming gases to the atmosphere
than does any other industry (18), with dairy and beef production being the
cause of most of this. It is therefore interesting to observe that, while a
nutrition-friendly food policy in both Europe, North America, and Australia,
etc., would necessitate a reduction in beef and dairy production and
consumption, with increased production and consumption of fruit and
vegetables, such policy movement would also be consistent with environmental
protection and reduction in global warming gas production (19). Accordingly,
it is at last becoming recognised that we need to develop policies for sustainable
healthy nutrition, to incorporate together agricultural and food industry policy,
public health nutrition policy, and policy for environmental sustainability (20).
O`Flaherty and Guzman (21) have described how there are lessons to be learned
from other public health successes, such as in the case of tobacco; they also
describe how much there is to do to encourage the food industry to comply with
objectives to provide our populations with much healthier food products than
are many of those they sell currently, especially in the context of any
meaningful attempts to address seriously the world`s obesity epidemic.

Health inequalities and the social determinants of health, and sustainable

healthy nutrition, both provide major challenges to the manner in which
developed societies and countries are organised. It remains to be seen whether
the advocates promoting both sustainable healthy nutrition and policies
designed to address the social determinants of health can obtain sufficient
prominence amongst all political priorities so as to effect the genuine changes in
public policy which are needed, if these public health challenges are at last to be
met effectively. If this is not achieved, this can only indicate the relative
ineffectiveness of public health in the twenty first century.

References:

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